Rhon D, Kim M, Asche C, Allison S, Allen C, Deyle G

Physical therapy and glucocorticoid injections are initial treatment options for knee osteoarthritis, but available data indicate that most patients receive one or the other, suggesting they may be competing interventions. The initial cost difference for treatment can be substantial, with physical therapy often being more expensive at the outset, and cost-effectiveness analysis can aid patients and clinicians in making decisions. The objective of this study is to investigate the incremental cost-effectiveness between physical therapy and intra-articular glucocorticoid injection as initial treatment strategies for knee osteoarthritis. This economic evaluation is a secondary analysis of a randomized clinical trial performed from October 1, 2012, to May 4, 2017. Health economists were blinded to study outcomes and treatment allocation. A randomized sample of patients seen in primary care and physical therapy clinics with a radiographically confirmed diagnosis of knee osteoarthritis were evaluated from the clinical trial with 96.2% follow-up at 1 year.

Rhon, D., Minchul, K., Asche, C., Allison, S., Allen, C., & Deyle, G. (2022). Cost-effectiveness of Physical Therapy vs Intra-articular Glucocorticoid Injection for Knee Osteoarthritis: A Secondary Analysis From a Randomized Clinical Trial. JAMA Network Open. https://doi.org/10.1001/jamanetworkopen.2021.42709

Rhon D, Oh R, Teyhen D

The DoD has a specific mission that creates unique challenges for the conduct of clinical research. These unique challenges include (1) the fact that medical readiness is the number one priority, (2) understanding the role of military culture, and (3) understanding the highly transient flow of operations. Appropriate engagement with key stakeholders at the point of care, where research activities are executed, can mean the difference between success and failure. These key stakeholders include the beneficiaries of the study intervention (patients), clinicians delivering the care, and the military and clinic leadership of both. Challenges to recruitment into research studies include military training, temporary duty, and deployments that can disrupt availability for participation. Seeking medical care is still stigmatized in some military settings. Uniformed personnel, including clinicians, patients, and leaders, are constantly changing, often relocating every 2-4 years, limiting their ability to support clinical trials in this setting which often take 5-7 years to plan and execute. When relevant stakeholders are constantly changing, keeping them engaged becomes an enduring priority. Military leaders are driven by the ability to meet the demands of the assigned mission (readiness). Command endorsement and support are critical for service members to participate in stakeholder engagement panels or clinical trials offering novel treatments. To translate science into relevant practice within the Military Health System, early engagement with key stakeholders at the point of care and addressing mission-relevant factors is critical for success.

Rhon, D., Oh, R., & Teyhen, D. (2021). Challenges With Engaging Military Stakeholders for Clinical Research at the Point of Care in the U.S. Military Health System. Military Medicine. https://doi.org/10.1093/milmed/usab494

Rhon D, Fraser J, Sorensen J, Greenlee T, Jain T, Cook C

This article was selected by JOSPT’s award committee to receive the 2021 JOSPT Guy G. Simoneau Excellence in Research Award.

The objective of this study was to investigate the influence of time taken to begin musculoskeletal rehabilitation on injury recurrence and one-year ankle-related medical care costs.

Rhon, D., Fraser, J., Sorenson, J., Greenlee, T., Jain, T., & Cook, C. (2021). Delayed Rehabilitation is Associated with Recurrence and Higher Medical Care Use After Ankle Sprain Injuries in the United States Military Health System. Journal of Orthopaedic & Sports Physical Therapy. https://doi.org/10.2519/jospt.2021.10730

Rhon D, Greenlee T, Dickens J, Wright A

Military females sustain higher rates of lower extremity injuries compared to males. This can include intra articular pathology in the hip. Females are considered to have worse outcomes following hip arthroscopy for femoroacetabular impingement and for hip labral repair. To confirm these statements, we queried the current literature.

Rhon, D., Greenlee, T., Dickens, J., & Wright, A. (2021). Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review. Orthopaedic Journal of Sports Medicine. https://doi.org/10.1177/23259671211053034

cook c, sheean a, zhou l, kyong m, rhon d

This study aims to determine whether surgery for cruciate ligament (anterior or posterior) or meniscus injury increased risks of subsequent comorbidities in beneficiaries of the Military Health System. The study was a retrospective case-control design in which individuals with cruciate or meniscus injuries were divided into two groups (surgery or none). Data were pulled 12 months prior and 24 months following each respective event and presence of comorbidities were compared between the two groups. Bivariate analyses and logistic regression were used to determine if surgery increased the odds of comorbidities. Participants included 1,686 with a cruciate ligament injury (30.1% treated surgically) and 13,146 with a meniscus injury (44.4% treated surgically). Bivariate comparisons of surgery versus nonsurgical treatment found multiple significant differences. After adjusting for covariates, a significant (p < 0.05) protective effect was seen only for meniscus surgery for concussion, insomnia, other mental health disorders, depression, and substance abuse. Surgery had no increased/decreased risk of comorbidities for cruciate ligament injuries. For meniscus injuries, surgery demonstrated a protective effect for six of the comorbidities we assessed. The treatment approach (surgery vs. nonsurgical) did not change the risk of comorbidities in those with a cruciate ligament injury. It is noteworthy that three of the six comorbidities involved mental health disorders. Although the study design does not allow for determination of causation, these findings should compel future prospective study designs that could confirm these findings.

Cook CE, Sheean AJ, Zhou L, Min KS, Rhon DI. Does Surgery for Cruciate Ligament and Meniscus Injury Increase the Risk of Comorbidities at 2 Years in the Military System? J Knee Surg. 2023 Apr;36(5):465-474. doi: 10.1055/s-0041-1736197. Epub 2021 Oct 5. PMID: 34610640.

Knotkova H, Hamani C, Sivanesan E, Elgueta Le Beuffe MF, Moon JY, Cohen SP, Huntoon MA

Neuromodulation is an expanding area of pain medicine that incorporates an array of non-invasive, minimally invasive, and surgical electrical therapies. In this Series paper, we focus on spinal cord stimulation (SCS) therapies discussed within the framework of other invasive, minimally invasive, and non-invasive neuromodulation therapies. These therapies include deep brain and motor cortex stimulation, peripheral nerve stimulation, and the non-invasive treatments of repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation. SCS methods with electrical variables that differ from traditional SCS have been approved. Although methods devoid of paraesthesias (eg, high frequency) should theoretically allow for placebo-controlled trials, few have been done. There is low-to-moderate quality evidence that SCS is superior to reoperation or conventional medical management for failed back surgery syndrome, and conflicting evidence as to the superiority of traditional SCS over sham stimulation or between different SCS modalities. Peripheral nerve stimulation technologies have also undergone rapid development and become less invasive, including many that are placed percutaneously. There is low-to-moderate quality evidence that peripheral nerve stimulation is effective for neuropathic pain in an extremity, low quality evidence that it is effective for back pain with or without leg pain, and conflicting evidence that it can prevent migraines. In the USA and many areas in Europe, deep brain and motor cortex stimulation are not approved for chronic pain, but are used off-label for refractory cases. Overall, there is mixed evidence supporting brain stimulation, with most sham-controlled trials yielding negative findings. Regarding non-invasive modalities, there is moderate quality evidence that repetitive transcranial magnetic stimulation does not provide meaningful benefit for chronic pain in general, but conflicting evidence regarding pain relief for neuropathic pain and headaches. For transcranial direct current stimulation, there is low-quality evidence supporting its benefit for chronic pain, but conflicting evidence regarding a small treatment effect for neuropathic pain and headaches. For transcutaneous electrical nerve stimulation, there is low-quality evidence that it is superior to sham or no treatment for neuropathic pain, but conflicting evidence for non-neuropathic pain. Future research should focus on better evaluating the short-term and long-term effectiveness of all neuromodulation modalities and whether they decrease health-care use, and on refining selection criteria and treatment variables.

Knotkova, H., Hamani, C., Sivanesan, E., Elgueta Le Beuffe, M., Youn Moon, J., Cohen, S., & Huntoon, M. (2021). Neuromodulation for chronic pain. The Lancet. https://doi.org/10.1016/S0140-6736(21)00794-7

Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W

Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage. The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles. The symptoms observed in nociplastic pain include multifocal pain that is more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage, as well as other CNS-derived symptoms, such as fatigue, sleep, memory, and mood problems. This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain. It is important to recognize this type of pain, since it will respond to different therapies than nociceptive pain, with a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.

Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W. (2021). Nociplastic Pain: Towards an Understanding of Prevalent Pain Conditions. The Lancet. https://doi.org/10.1016/S0140-6736(21)00392-5

Cohen S, Vase L, Hooten W

Chronic pain exerts an enormous personal and economic burden, affecting more than 30% of people worldwide according to some studies. Unlike acute pain, which carries survival value, chronic pain might be best considered to be a disease, with treatment (eg, to be active despite the pain) and psychological (eg, pain acceptance and optimism as goals) implications. Pain can be categorized as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitized nervous system), all of which affect work-up and treatment decisions at every level; however, in practice there is considerable overlap in the different types of pain mechanisms within and between patients, so many experts consider pain classification as a continuum. The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realize that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management. Clinical trials and guidelines typically recommend a personalized multimodal, interdisciplinary treatment approach, which might include pharmacotherapy, psychotherapy, integrative treatments, and invasive procedures.

Cohen SP, Vase L, Hooten WM. (2021). Chronic Pain: An Update on Burden, Best Practices, and New Advances. Lancet. https://doi.org/10.1016/S0140-6736(21)00393-7

Knox N, Lee C, Moon J, Cohen S

The objective of this multicenter prospective study was to determine the prevalence and breakdown of pain symptoms among patients with coronavirus disease 2019 (COVID-19) infection admitted for non-pain symptoms and the association between the presence of pain and intensive care unit (ICU) admission and death. Data on the intensity and type of pain were collected on 169 patients with active severe acute respiratory syndrome coronavirus 2 infection at 2 teaching hospitals in the United States and Korea and on 8 patients with acute pain at another large teaching hospital between February 1, 2020, and June 15, 2020. Results showed that acute pain is common during active COVID-19 infection with the most common manifestations being headache, chest pain and spine pain. Individuals without pain were more likely to require intensive care and expire than those with pain. Reasons why pain may be associated with reduced mortality include that an intense systemic stimulus (eg, respiratory distress) might distract pain perception or that the catecholamine surge associated with severe respiratory distress might attenuate nociceptive signaling.

Knox N, Lee C, Moon JY, Cohen SP. (2021). Pain Manifestations of COVID-19 and Their Association with Mortality: A Multicenter Prospective Observational Study. Mayo Clinic Proceedings. https://doi.org/10.1016/j.mayocp.2020.12.014.

Chen Y, Vu T, Chinchilli V, Farrag M, Roybal A, Huh A, Cohen ZO, Becker A, Arvanaghi B, Agrawal M, Ogden J, Cohen S

There has been a surge in interest in radiofrequency ablation (RFA) of the genicular nerves over the past decade, with wide variability in selection, technique and outcomes. The aim of this study is to determine factors associated with treatment outcome. They retrospectively evaluated the effect of 23 demographic, clinical and technical variables on outcomes in 265 patients who underwent genicular nerve RFA for knee pain at 2 civilian and 1 military hospital. A primary outcome was designated as a > 30% decrease in average knee pain score lasting at least 3 months without cointerventions.

Chen, Y., Vu, T. N., Chinchilli, V., Farrag, M., Roybal, A., Huh, A., Cohen, Z., Becker, A., Arvanaghi, B., Agrawal, M., Ogden, J., & Cohen, S. (2021). Clinical and technical factors associated with knee radiofrequency ablation outcomes: A multicenter analysis. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2020-102017

Kohan L, Durbhakula S, Zaidi M, Phillips C, Rowan C, Brenner G, Cohen S

The coronavirus disease 2019 (COVID-19) pandemic is a public health crisis of unprecedented proportions that has altered the practice of medicine. The pandemic has required pain clinics to transition from in-person visits to telemedicine, postpone procedures, and cancel face-to-face educational sessions. There are no data on how fellowship programs have adapted. A 17-question survey was developed covering topics including changes in education, clinical care, and psychological stress due to the COVID pandemic. Results showed a shift to online alternatives for clinical care and education, with correlations between per capita infection rates, and clinical care demands and redeployment, but not with overall trainee anxiety levels. It is likely that medicine in general, and pain medicine in particular, will change after COVID-19, with greater emphasis on telemedicine, virtual education, and greater national and international cooperation. Physicians should be prepared for these changes.

Kohan, L., Durbhakula, S., Zaidi, M., Phillips, C., Rowan, C., Brenner, G., & Cohen, S. (2021). Changes in Pain Medicine Training Programs Associated With COVID-19: Survey Results. Anesthesia & Analgesia. https://doi.org/10.1213/ANE.0000000000005314

Cohen S, Doshi T, Kurihara C, Dolomisiewicz E, Liu R, Dawson T, Hager N, Durbhakula S, Verdun A, Hodgson J, Pasquina P

The rising use of injections to treat low back pain (LBP) has led to efforts to improve selection. Nonorganic (Waddell) signs have been shown to portend treatment failure for surgery and other therapies but have not been studied for minimally invasive interventions. This study prospectively evaluated the association between Waddell signs and treatment outcome in 3 cohorts: epidural steroid injections (ESI) for leg pain and sacroiliac joint (SIJ) injections and facet interventions for LBP. Categories of Waddell signs included nonanatomic tenderness, pain during sham stimulation, discrepancy in physical examination, overreaction, and regional disturbances divulging from neuroanatomy. The primary outcome was change in patient-reported “average” numerical rating scale for pain intensity (average NRS-PI), modeled as a function of the number of Waddell signs using simple linear regression. Secondary outcomes included a binary indicator of treatment response. Secondary and sensitivity analyses were conducted to account for potential confounders. Whereas this study found no consistent relationship between Waddell signs and decreased mean pain scores, a significant relationship between the number of Waddell signs and treatment failure was observed.

Cohen, S., Doshi, T., Kurihara, C., Dolomisiewicz, E., Liu, R., Dawson, T., Hager, N., Durbhakula, S., Verdun, A., Hodgson, J., & Pasquina, P. (2021). Waddell (Nonorganic) Signs and Their Association with Interventional Treatment Outcomes for Low Back Pain. Anesthesia & Analgesia. https://doi.org/10.1213/ANE.0000000000005054

Cohen S, Provenzano D, Narouze S

Cohen SP, Provenzano DA, Narouze S. (2021). Facet guidelines, serial medial branch blocks and issues surrounding recommending procedures with no mechanistic foundation. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2020-101634.

Crowell M, Brindle R, Mason J, Pitt W, Miller E, Posner M, Cameron K, Goss D

There is a large incidence of shoulder instability among active young athletes and military personnel. Shoulder stabilization surgery is the commonly employed intervention for treating individuals with instability. Following surgery, a substantial proportion of individuals experience acute post-operative pain, which is usually managed with opioid pain medications. Unfortunately, the extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, but there are currently few alternatives. However, Battlefield Acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain.

Crowell, M., Brindle, R., Mason, J., Pitt, W., Miller, E., Posner, M., Cameron, K., & Goss, D. (2020). The effectiveness of battlefield acupuncture in addition to standard physical therapy treatment after shoulder surgery: a protocol for a randomized clinical trial. Trials. https://doi.org/10.1186/s13063-020-04909-8

Symsack A, Gaunaurd I, Thaper A, Springer B, Bennett C, Clemens S, Lucarevic J, Kristal A, Sumner M, Isaacson B, Pasquina P, Gailey R

Telehealth is an increasingly common approach to improve healthcare delivery, especially within the Veterans Health Administration and Department of Defense (DoD). Telehealth has diminished many challenges to direct access for clinical follow-up; however, the use of mobile telehealth for specialty rehabilitative care is emerging and is referred to as telerehabilitation. As early adopters of telehealth, the Veterans Affairs and DoD have supported collaborated efforts for programs designed to increase the access and quality of rehabilitative care while improving the functional ability of our service members (SMs) and veterans with lower limb amputation (LLA). The DoD and Veterans Health Administration collaborated on a Mobile Device Outcomes-based Rehabilitation Program (MDORP) to help injured SMs and veterans with LLA. The MDORP project utilized a mobile health system called the Rehabilitative Lower Limb Orthopedic Accommodating Device (ReLOAD) to assess walking quality. The ReLOAD system includes real-time auditory biofeedback to notify the user of their most prominent gait deviation and then recommends exercises that address specific balance and strength impairments. The purpose of this study was to describe the responses to a postintervention survey evaluating the feasibility and usability of ReLOAD completed by SMs and veterans with LLA who used the system for 5 months.

Symsack, A., Gaunaurd, I., Thaper, A., Springer, B., Bennett, C., Clemens, S., Lucarevic, J., Kristal, A., Sumner, M., Isaacson, B., Pasquina, P., & Gailey, R. (2020). Usability Assessment of the Rehabilitation Lower-limb Orthopedic Assistive Device by Service Members and Veterans with Lower Limb Loss. Military Medicine. https://doi.org/10.1093/milmed/usaa428

Isaacson B, Miranda M, Hager N, Wagner L, West S, Lucio W, Heller J, Dalgarno R, Dickens J, Schoomaker E, Pasquina P

The cost of health care in the United States has increased exponentially over the past 60 years, soaring from $27.2 billion in 1960 (5% of gross domestic product) and $147 per resident to $3.5 trillion (17.9% of gross domestic product) and $11 000 per resident in 2017. Health care expenditures continue to rise significantly faster than the median household income, and this poses a financial strain for patients, providers, and the health care system alike. Removing unnecessary variation through evidence-based medicine is critical to improving outcomes and making care more affordable. This may be accomplished through standardized protocols, order sets, and check lists, with positive results previously demonstrated for obstetrics/gynecology, critical care, pediatrics, gastrointestinal surgery, orthopedics, and rehabilitation. Effective communication with a multidisciplinary team has also shown to enhance quality of treatment, reduce complications, and decrease postoperative issues. Although treatment normalization is a pragmatic solution for removing health care waste, evidence supports that even when guidelines are available, only two-thirds of patients receive the recommended care, and another quarter get treatment that may be unnecessary and/or harmful.

Isaacson B., Miranda M., Hager N., Wagner L., West S., Lucio W., Heller J., Dalgarno R., Dickens J., Schoomaker E., Pasquina P. (2020). Standardizing Postoperative Rehabilitation Protocols for the Tri-Service: A Consensus Meeting Hosted by the Musculoskeletal Injury Rehabilitation Research for Operational Readiness Organization. Military Medicine. https://doi.org/10.1093/milmed/usaa207

Velasco T, Leggit J

Chronic exertional compartment syndrome is a debilitating condition primarily associated in highly active individuals with an estimated incidence of approximately 1 in 2000 persons/year. The etiology remains unclear to date. The differential diagnosis includes, but is not limited to stress fractures, medial tibial stress syndrome, and popliteal artery entrapment syndrome. Clinical signs and symptoms include pain in the involved compartment with exertion dissipating quickly after activity. Diagnostic tests include intramuscular compartment pressure testing, magnetic resonance imaging, near-infrared spectrometry as well as shear wave electrography. Treatments consist of nonsurgical, surgical, or the combination of the two. Gait retraining and the use of botulinum toxin appear most promising. Diagnostic lidocaine injections are emerging as a prognostic and mapping tool. Minimal invasive surgical options are being utilized allowing quicker return to activity and decreased morbidity. This article reviews the anatomy, clinical signs and symptoms, diagnostics, nonsurgical, and surgical treatments for chronic exertional compartment syndrome.

Velasco, Teonette O. PT, DPT, OCS; Leggit, Jeffrey C. MD, CAQSM. Chronic Exertional Compartment Syndrome: A Clinical Update. Current Sports Medicine Reports 19(9):p 347-352, September 2020. https://doi.org/10.1249/JSR.0000000000000747

Cohen S, Baber Z, Buvanedran A, Mclean b, chen y, hooten wm, laker s, wasan a, kennedy d, sandbrink f

It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for.

In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization.

Pain Medicine, Volume 21, Issue 7, July 2020, Pages 1331–1346, https://doi.org/10.1093/pm/pnaa127

Shanthanna H, Strand N, Provenzano D, Lobo C, Eldabe S, Bhatia A, Wegener J, Curtis K, Cohen S, Narouze S

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgeries, procedures, and patient visits, including pain management services, have been postponed or cancelled. This has impacted the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognized during this pandemic for chronic pain patients include ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritizing necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Shanthanna H., Strand N.H., Provenzano D.A., Lobo C.A., Eldabe S., Bhatia A., Wegener J., Curtis K., Cohen S.P., Narouze S. (2020). Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel. Anesthesia. https://doi.org/10.1111/anae.15076

Cohen S, Bhaskar A, Bhatia A, Buvanendran A, Deer T, Garg S, Hooten M, Hurley R, Kennedy D, McLean B, Moon J, Narouze S, Pangarkar S, Provenzano D, Rauck R, Sitzman B, Smuck M, Zundert J, Vorenkamp K, Wallace M, Zhao Z

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial. Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Cohen SP, Bhaskar A, Bhatia A, et al. (2020). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2019-101243